Primary Care Optometry in Namibia

Dip Optom FOA(SA), MC Optom (UK), TMOD (US), CAS (NECO), D Optom (UK), FSLS

Outline

Who am I?
WCO definition of optometry
Is there a need for primary care optometry?
Prevalence and management of glaucoma and diabetes
What are optometrist currently doing?
What should optometrists be doing?
What about ophthalmology?
What about additional training?

WCO Definition of Optometry

“Optometry is a health care profession that is autonomous, educated and regulated (licensed/ registered),
optometrists are the primary health care practitioners of the eye and visual system who provide comprehensive eye and vision care, which includes refraction and dispensing,
the detection/ diagnosis and management of disease in the eye and the rehabilitation of conditions of the visual system”

What drives the Recognition, development and scope of a profession

The establishment, recognition and development of any profession depends on the perceived need for the profession in that country
Great efforts have been made towards developing the profession of optometry, yet we fail to reap the rewards

Recognition and Legalization

Development of optometry in Africa has been adversely affected by opposition from organised medicine, lack of scope and slow legislative changes, inadequate education, poor service delivery and lack of posts in public health institutions
“Optometry is supposed to be part of the primary healthcare system but it hasn’t yet been integrated into the system….”

Dr Udak Christabel Udom – President of the WCO and past president of AFCO and NOA

Causes of blindness in Africa

Pie charts - causes of avoidable blindness in Africa and number of people blind, Africa vs rest of the world

What about blindness caused by refractive error? 18% globally, probably much higher in Africa
Refractive error is the main cause of visual impairment in the 5 – 15yr old group globally

What can be done to prevent avoidable blindness?

WHO infographic - opportunities and actions to prevent avoidable blindness

Namibian Population Data

Source: http://countrymeters.info/en/Namibia

During 2017 Namibia population is projected to increased by 57,953 people and reach 2,600,857 in the beginning of 2018
870,665 young people under 15 years old
1,568,031 persons between 15 and 64 years old
104,208 persons above 64 years old
Total life expectancy (both sexes) at birth for Namibia is 52.2 years
87.5% African, 6.5% white
How many receive care in the public sector?

Number of Ophthalmologists in South Africa and Namibia

324 Ophthalmologists in South Africa, only 70 of these in public sector
Only 82% doing surgery
This averages 6 ophthalmologists per million of population overall
Only 70 in public sector – serving 40 million people or 1:500,000

Namibia, 3 ophthalmologists per 1 million, total of 7 in practice
How many in public sector?
Ophthalmologists ratio per public sector?
IOC also states that the number of ophthalmologists unlikely in SA (and Namibia) unlikely to change

Number of Optometrists in Namibia

90 Optometrists
Ratio 1:28800 considering total population
Majority in private sector
Very few in public sector
- Due in part to the lack of public sector posts
Very few involved in primary eye care
- Due to restriction on scope of the profession
- Lack of specialised training
World wide only around 30% of practitioners convert to tier 4 of the WCO Global Competency Based Model of Scope

What is the ideal ratio for Africa?

According to the WHO the ideal ratio per population is:

Ophthalmology 1:250 000
Optometry 1:10 000

Currently in Africa:

Ophthalmology averages around 1:1 million
Optometry 1:100 000

Glaucoma in South Africa and Africa

Prevalence of glaucoma	Studies
• 5% of African population in South Africa have glaucoma • Similar numbers are reported for African Cameroonians • 5.6% prevalence in Ghana • 4.2% prevalence in Tanzania • 1.5% prevalence among white South Africans	• Rotchford & Johnson. Arch Ophthalmol. 2002 Apr; 120(4):471-8. • Rotchford et al. Ophthalmology. 2003 Feb; 110(2):376-82. • Salmon et al. Arch Ophthalmol. 1993 Sep; 111(9):1263-9. • Ellong et al, Sante 2006 Apr-Jun;16(2):83-8.
• The SA prevalence is lower than estimates of 7% for Africans in Ghana and in Barbados (Caribbean)	• Ntim-Amponsah et al. Eye (2004) 18, 491–497. • Fatima Kyari et al. Middle East Afr J Ophthalmol

POAG 5% in > 40 year old people of African ancestry

Glaucoma

Glaucoma is a chronic, incurable eye disease resulting in loss of vision and ultimately blindness
Although the disease cannot be cured, treatment is aimed at maintaining vision throughout life – Saved Sight Years
1–2 mmHg higher than target IOP = 10–20% more rapid progression, patient develops serious field loss*
1–2 mmHg lower than target IOP = 10–20% slower progression, patient avoids serious field loss*

*Heijl et al. Acta Ophthalmol 2013;91:406–12

Predicting the burden of glaucoma care in Namibia

According to population data ± 2.3 million people of African ancestry reside in Namibia
1.5 million of them are between 16 and 64, and 104 000 are older than 64 years
Lest assume 800 00 is over 35 years
If 5% of the population over 35 years have glaucoma then the number of African citizens in Namibia with glaucoma is (800 000 x 5%) 40 000 *

*Up to 50% of glaucoma remains undiagnosed – QUIGLEY, H. A. & BROMAN, A. T. 2006. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol, 90, 262-7

GLAUCOMA

Management

South African Glaucoma Society Guidelines and European Glaucoma Society Guidelines state the following:

Every new glaucoma patient should receive:

Comprehensive clinical examination including:
Slit-lamp examination,
Tonometry,
Fundus and optic nerve head examination,
Gonioscopy,
Corneal thickness measurement,
Special investigations to document the extent of structural damage to the optic nerve head and the retinal nerve fiber layer: OCT, disc photography, computer assisted visual field analysis,
Comprehensive discussion and information session to answer questions and educate the patient on the disease

Cover of the European Glaucoma Society Terminology and Guidelines for Glaucoma

Follow up FOR CONTROLLED PATIENTS:

Patients should be seen 3 times per year

Follow up FOR UNCONTROLLED PATIENTS:

Patients may need to be seen up to 6 times per year

Let’s Do the Math

40 000 cases of glaucoma in just the African community in Namibia
If half are stable and half are not, then the EGS guidelines require 3 visits per year for controlled patients = 60 000 visits in Namibia
In uncontrolled cases up to 6 visits per year = 100 000 visits in Namibia
TOTAL = 160 000 visits are needed to take care of non-surgical glaucoma in Namibia
Assuming each visits lasts only 15 minutes, that would require 40 000 hours in Namibia
Note that this is only “doctor time” and assumes there are assistants doing all ancillary tests (and leaving no time for the doctor to later review any of these tests)
A person working a 40 hour work week for 48 weeks/year = 1920 hours per year
To provide 40 000 hours of care would require 20 ophthalmologists working full time, SOLELY on the non-surgical, medical care of glaucoma patients –not counting any care for cataract, diabetic retinopathy, macular degeneration or even glaucoma surgical care (not to mention routine red eye cases, all other eye diseases)

…and thats before we even begin to talk about the Diabetes Tsunami

World map of diabetes prevalence by country

In 2015, 415 million people world wide had diabetes, this included 14 million people in Africa
It is projected that these figures will double by 2040

Diabetic retinopathy

Social Impact of Vision Loss

Everyone with diabetes is at risk of diabetic retinopathy - eye examination in Africa

Less access to health support services
Loss of independence and dignity
Need for greater social support
Women and girls suffer most

Consequences of visual impairment infographic

Timing of Eye Screening

Retinopathy screening	Type 1 diabetes	Type 2 diabetes	Gestational diabetes
Initial	5 years after diagnosis	As soon as possible after diagnosis	As soon as possible after diagnosis
Ongoing	Yearly	Yearly	If diabetes resolves after pregnancy no further screening needed

Diabetes in Namibia

Prevalence of diabetes is 5,4% of the population
2,6 million people >140 000 people with diabetes in Namibia

Let’s do the math

The numbers here are much harder to calculate but if we assume just 1 dilated exam annually averaging 10 min, not counting time to dilate
23330 hours of care per year in Namibia
Again, one person working a 40 hour work week for 48 weeks/year equals 1920 hours per year.
That’s another 12 ophthalmologists doing nothing but dilated fundus examinations on KNOWN diabetics once a year, without any FAs, no PRPs, no vitrectomies…..

To Summarize

Theoretically, Namibia require at least 32 ophthalmologists, spending ALL their time, just to cope with the burden of glaucoma and diabetes
What about cataracts, surgical glaucoma, dry eye, VKC, contact lens complications, and all the other eye disease commonly encountered in practice?
This is a similar situation to many other countries, not only in Africa but all over the world

How should the gap be filled?

There are three options:

Dramatically increase the output of ophthalmologists
Create a new medical specialty of non-surgical ophthalmology that could be trained quicker and cheaper than surgeons
Fundamentally upgrade the training of optometrists, freeing surgeons to do more surgery and vastly increasing the portals of entry for routine medical eye care
Add more assistants, nurses, to the staff of the present number of ophthalmologists, teaching them to manage disease under the direct supervision of an ophthalmologist

Other Role Players

“Besides optometrists and ophthalmologists, there are other players in this game
GPs diagnose and treat ocular pathology all the time
Occupational health nurses and pharmacists do too. And then of course there are the homeopaths, faith-healers, sangomas, inyangas and many others
Compared to all of these players, optometrists are far and away the most skilled and knowledgeable about eye diseases. Not only because they concentrate just on eyes and vision every day, all day, but because they have the instruments that enable proper diagnosis”

Dr Clive Novis, As I see it: Ophthalmology versus optometry; Vol 11 | No 4 • Spring 2016 SA Ophthalmology Journal 46

Education before legislation

Cartoon - sign on the wall reads First pants, THEN your shoes

Acquisition and Development of New Clinical Skills

(Kennedy report)

“Any clinician carrying out any clinical procedure for the first time must be directly supervised by colleagues who have the necessary skill, competence and experience until such time as the relevant degree of expertise has been acquired”

WCO Global Competency Based Model of Scope of Practice in Optometry

Addressed the diversity in optometric qualifications by establishing a four step ladder of qualifications
Dispensing optics (level 1)
Refractive and investigative functions (level 2)
Diagnostics (level 3)
Full scope optometry (level 4)
Namibia is currently at level 2
Postgraduate courses in ocular diagnostics and therapeutic prescribing are available in South Africa, the USA, UK, Australia and New Zealand
Currently optometric therapeutic prescribing is an entirely post graduate qualification

Why Upgrade the Training of Optometrists?

ADVANTAGES
- Much broader access to eye care in widely dispersed community-based clinics overseen by independently registered optometrists
- Individuals providing care are each personally liable for their care
DISADVANTAGES
- This will require invention and training of a provider very different from today’s average optometrist
- Implementation of specialized training to meet the needs of the specific community or country these optometrist serve – decolonization of education

This option is the one that has been chosen most often around the world

Namibian Optometrists – Survey

More than 30% of Namibian practitioners responded

What is your highest level of optometric training?

B Optom or equivalent degree	B.Optometry with DPA’s
Certificate of advanced studies (CAS) or equivalent in diagnostics and therapeutics	CAS > 10 with DPA’s none with TPA’s
Master’s degree	None
Doctorate	None
Other	> 5 Sport Vison / Diabetic certificates

Do you currently manage or co-manage any of the following conditions and if so do you feel you are competent to do so or do you need additional training?

Bar chart - conditions Namibian optometrists manage or co-manage, competence and training needs

Which of the following specialised equipment do you currently have or plan to invest in?

Bar chart - specialised equipment Namibian optometrists have or plan to invest in

Which of the following topical ophthalmic drugs do you frequently use or feel optometrist should be able to use with appropriate training?

Bar chart - topical ophthalmic drugs Namibian optometrists use or would use with training

If ocular diagnostics and ocular therapeutics for optometrists are introduced in Namibia, how soon would you like to see this happen?

Bar chart - how soon respondents would like ocular diagnostics and therapeutics introduced

What is the Opinion of Ophthalmology?

“Today’s optometrists have the whole world of Ophthalmology at the click of a button. They can look up anything ophthalmological in seconds on Google. They can watch anything ophthalmological on YouTube. The old argument that their knowledge is inadequate no longer holds water. It’s a different world now”
Dr Clive Novis, As I see it: Ophthalmology versus optometry; Vol 11 | No 4 • Spring 2016 SA Ophthalmology Journal 46

“Optometrists are in an excellent position to diagnose and treat certain ocular conditions without posing a danger to the public. There are also now formal courses available for optometrists who want to expand their abilities to diagnose and treat certain ocular conditions”
“These are the type of optometrists who can make a great contribution to South Africa with its inadequate supply of ophthalmologists. Red tape, rules and regulations should not stand in their way”